Incidence of Delirium in Critically Ill Patients With and Without COVID-19.

BACKGROUND: It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19. METHODS: This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium. RESULTS: Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p < 0.001). Among patients mechanically ventilated for two days or more, the incidence of delirium did not differ between groups (COVID-19: 89/211, 42.1% vs non-COVID-19: 19/47, 40.4%; p = 0.82). Logistic regression showed that the duration of mechanical ventilation was the only independent factor associated with delirium (p = 0.001). CONCLUSION: COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.

Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network, and the General Coordination of the National Transplant System. / Diretrizes brasileiras para o manejo de potenciais doadores de órgãos em morte encefálica. Uma força-tarefa composta por Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network e Coordenação Geral do Sistema Nacional de Transplantes.

OBJECTIVE: To contribute to updating the recommendations for brain-dead potential organ donor management. METHODS: A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, answered questions related to the following topics were divided into mechanical ventilation, hemodynamics, endocrine-metabolic management, infection, body temperature, blood transfusion, and checklists use. The outcomes considered were cardiac arrests, number of organs removed or transplanted as well as function / survival of transplanted organs. The quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system to classify the recommendations. RESULTS: A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong, 11 as weak and 1 was considered a good clinical practice. CONCLUSION: Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak.

OBJETIVO: Fornecer recomendações para nortear o manejo clínico do potencial doador em morte encefálica. MÉTODOS: O presente documento foi formulado em dois painéis compostos por uma força tarefa integrada por 27 especialistas de diferentes áreas que responderam a questões dirigidas aos seguintes temas: ventilação mecânica, hemodinâmica, suporte endócrino-metabólico, infecção, temperatura corporal, transfusão sanguínea, e uso de checklists. Os desfechos considerados foram: parada cardíaca, número de órgãos retirados ou transplantados e função/sobrevida dos órgãos transplantados. A qualidade das evidências das recomendações foi avaliada pelo sistema Grading of Recommendations Assessment, Development, and Evaluation. RESULTADOS: Foram geradas 19 recomendações a partir do painel de especialistas. Dessas, 7 foram classificadas como fortes, 11 fracas e uma foi considerada boa prática clínica. CONCLUSÃO: Apesar da concordância entre os membros do painel em relação à maior parte das recomendações, o grau de recomendação é fraco em sua maioria.

Diretrizes brasileiras para o manejo de potenciais doadores de órgãos em morte encefálica. Uma força-tarefa composta por Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network e Coordenação Geral do Sistema Nacional de Transplantes / Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Transplantes de Órgãos, Brazilian Research in Critical Care Network, and the General Coordination of the National Transplant System

RESUMO Objetivo: Fornecer recomendações para nortear o manejo clínico do potencial doador em morte encefálica. Métodos: O presente documento foi formulado em dois painéis compostos por uma força tarefa integrada por 27 especialistas de diferentes áreas que responderam a questões dirigidas aos seguintes temas: ventilação mecânica, hemodinâmica, suporte endócrino-metabólico, infecção, temperatura corporal, transfusão sanguínea, e uso de checklists. Os desfechos considerados foram: parada cardíaca, número de órgãos retirados ou transplantados e função/sobrevida dos órgãos transplantados. A qualidade das evidências das recomendações foi avaliada pelo sistema Grading of Recommendations Assessment, Development, and Evaluation. Resultados: Foram geradas 19 recomendações a partir do painel de especialistas. Dessas, 7 foram classificadas como fortes, 11 fracas e uma foi considerada boa prática clínica. Conclusão: Apesar da concordância entre os membros do painel em relação à maior parte das recomendações, o grau de recomendação é fraco em sua maioria.

Abstract Objective: To contribute to updating the recommendations for brain-dead potential organ donor management. Methods: A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, answered questions related to the following topics were divided into mechanical ventilation, hemodynamics, endocrine-metabolic management, infection, body temperature, blood transfusion, and checklists use. The outcomes considered were cardiac arrests, number of organs removed or transplanted as well as function / survival of transplanted organs. The quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system to classify the recommendations. Results: A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong, 11 as weak and 1 was considered a good clinical practice. Conclusion: Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak.

Brazilian guidelines for the management of brain-dead potential organ donors. The task force of the AMIB, ABTO, BRICNet, and the General Coordination of the National Transplant System.

OBJECTIVE: To contribute to updating the recommendations for brain-dead potential organ donor management. METHOD: A group of 27 experts, including intensivists, transplant coordinators, transplant surgeons, and epidemiologists, joined a task force formed by the General Coordination Office of the National Transplant System/Brazilian Ministry of Health (CGSNT-MS), the Brazilian Association of Intensive Care Medicine (AMIB), the Brazilian Association of Organ Transplantation (ABTO), and the Brazilian Research in Intensive Care Network (BRICNet). The questions were developed within the scope of the 2011 Brazilian Guidelines for Management of Adult Potential Multiple-Organ Deceased Donors. The topics were divided into mechanical ventilation, hemodynamic support, endocrine-metabolic management, infection, body temperature, blood transfusion, and use of checklists. The outcomes considered for decision-making were cardiac arrest, number of organs recovered or transplanted per donor, and graft function/survival. Rapid systematic reviews were conducted, and the quality of evidence of the recommendations was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Two expert panels were held in November 2016 and February 2017 to classify the recommendations. A systematic review update was performed in June 2020, and the recommendations were reviewed through a Delphi process with the panelists between June and July 2020. RESULTS: A total of 19 recommendations were drawn from the expert panel. Of these, 7 were classified as strong (lung-protective ventilation strategy, vasopressors and combining arginine vasopressin to control blood pressure, antidiuretic hormones to control polyuria, serum potassium and magnesium control, and antibiotic use), 11 as weak (alveolar recruitment maneuvers, low-dose dopamine, low-dose corticosteroids, thyroid hormones, glycemic and serum sodium control, nutritional support, body temperature control or hypothermia, red blood cell transfusion, and goal-directed protocols), and 1 was considered a good clinical practice (volemic expansion). CONCLUSION: Despite the agreement among panel members on most recommendations, the grade of recommendation was mostly weak. The observed lack of robust evidence on the topic highlights the importance of the present guideline to improve the management of brain-dead potential organ donors.

Diretrizes para avaliação e validação do potencial doador de órgãos em morte encefálica / Guidelines for the assessment and acceptance of potential brain-dead organ donors

RESUMO O transplante de órgãos é a única alternativa para muitos pacientes portadores de algumas doenças terminais. Ao mesmo tempo, é preocupante a crescente desproporção entre a alta demanda por transplantes de órgãos e o baixo índice de transplantes efetivados. Dentre as diferentes causas que alimentam essa desproporção, estão os equívocos na identificação do potencial doador de órgãos e as contraindicações mal atribuídas pela equipe assistente. Assim, o presente documento pretende fornecer subsídios à equipe multiprofissional da terapia intensiva para o reconhecimento, a avaliação e a validação do potencial doador de órgãos.

ABSTRACT Organ transplantation is the only alternative for many patients with terminal diseases. The increasing disproportion between the high demand for organ transplants and the low rate of transplants actually performed is worrisome. Some of the causes of this disproportion are errors in the identification of potential organ donors and in the determination of contraindications by the attending staff. Therefore, the aim of the present document is to provide guidelines for intensive care multi-professional staffs for the recognition, assessment and acceptance of potential organ donors.

O Entendimento do Paciente sobre Hipertensão Arterial: uma Análise com Base no Risco Cardiovascular / The Patient’s Knowledge about Hypertension: an Analysis Based on Cardiovascular Risk

Fundamentos: O autoconhecimento da hipertensão arterial pode contribuir para seu melhor controle; no entanto,desconhece-se o quanto esse conhecimento é influenciado pela gravidade da própria doença.Objetivo: Avaliar o conhecimento de sujeitos com hipertensão arterial sistêmica sobre a própria doença com base no risco cardiovascular.Métodos: Estudo transversal, qualiquantitativo, com utilização de entrevista semiestruturada aplicada em113 sujeitos com hipertensão, acompanhados em uma Unidade Básica de Saúde de Joinville, SC, Brasil. Dadossocioeconômicos, antropométricos, laboratoriais e valores de pressão arterial foram considerados em cada grupo de risco cardiovascular, estratificados com base nas VI Diretrizes Brasileiras de Hipertensão Arterial.Resultados: A média de idade foi 57,8±10,0 anos, 64,0% de mulheres. A idade mais avançada, maior valor dapressão arterial sistólica e tempo de hipertensão, bem como a maior presença de diabetes, dislipidemia e tabagismo foram mais prevalentes no grupo de maior risco cardiovascular. O conhecimento envolvendo os fatores de risco e modificação do estilo de vida não foi diferente entre os grupos de risco cardiovascular. Apenas o conhecimentosobre as complicações associadas à hipertensão arterial foi menor no grupo de muito alto risco cardiovascular(p<0,001). Conclusão: O grupo de maior risco cardiovascular é aquele que evidencia maior desconhecimento sobre as complicações associadas à hipertensão arterial sistêmica.

Background: The patient’s knowledge about hypertension can contribute to the best control of it; however, the influence on such knowledge by the seriousness of the disease is unknown. Objective: Assessing the knowledge of individuals with arterial hypertension about their own disease based on the cardiovascular risk. Methods: Cross-sectional, quali-quantitative study, using semi-structured interview made with 113 individuals with hypertension,followed-up in a Basic Health Unit of Joinville, SC, Brazil. Social and economic, anthropometric, laboratorial data and blood pressure values were considered in each cardiovascular risk group, stratified based on the VI Brazilian Guidelines on Hypertension. Results: The mean age was of 57.8+10.0 years, 64.0% being women. The most advanced age, highest systolic blood pressure and hypertension time, as well as the higher rate of presence of diabetes, dyslipidemia and smoking were more predominant in the groupwith the highest cardiovascular risk. The knowledge about the risk factors and change in lifestyle was not different between the cardiovascular risk groups. Only the knowledge about the complications related to arterial hypertension was not as extensive in thegroup with very high cardiovascular risk (p<0.001). Conclusion: The group with the highest cardiovascular risk is the one showing the poorest knowledge about the complications related to hypertension.

Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido: Parte III. Recomendações órgãos específicas / Guidelines for potential multiple organ donors (adult). Part III: organ-specific recommendations

A morte encefálica induz várias alterações fisiopatológicas que podem causar lesões em rins, pulmões, coração e fígado. Portanto, a atuação do intensivista durante a manutenção do potencial doador falecido exige cuidados específicos com estes órgãos visando sua maior viabilidade para transplantes. O manejo hemodinâmico cuidadoso, os cuidados ventilatórios e de higiene brônquica minimizam a perda de rins e pulmões para o transplante. A avaliação da condição morfológica e funcional do coração auxilia na avaliação do potencial transplantável deste órgão. Por fim, a avaliação da função hepática, assim como o controle metabólico e a realização de sorologias virais são fundamentais para a orientação das equipes transplantadoras na seleção do órgão a ser doado e no cuidado com o receptor.

Brain death (BD) alters the pathophysiology of patients and may damage the kidneys, the lungs, the heart and the liver. To obtain better quality transplant organs, intensive care physicians in charge of the maintenance of deceased donors should attentively monitor these organs. Careful hemodynamic, ventilatory and bronchial clearance management minimizes the loss of kidneys and lungs. The evaluation of cardiac function and morphology supports the transplant viability assessment of the heart. The monitoring of liver function, the management of the patient's metabolic status and the evaluation of viral serology are fundamental for organ selection by the transplant teams and for the care of the transplant recipient.

Guidelines for potential multiple organ donors (adult). Part III: organ-specific recommendations. / Diretrizes para manutenção de múltiplos órgãos no potencial doador adulto falecido: Parte III. Recomendações órgãos específicas.

Brain death (BD) alters the pathophysiology of patients and may damage the kidneys, the lungs, the heart and the liver. To obtain better quality transplant organs, intensive care physicians in charge of the maintenance of deceased donors should attentively monitor these organs. Careful hemodynamic, ventilatory and bronchial clearance management minimizes the loss of kidneys and lungs. The evaluation of cardiac function and morphology supports the transplant viability assessment of the heart. The monitoring of liver function, the management of the patient's metabolic status and the evaluation of viral serology are fundamental for organ selection by the transplant teams and for the care of the transplant recipient.

Morbidade e mortalidade em hemodiálise: importância do seguimento pré-dialítico e da fonte de financiamento / Dialysis mortality: the role of referral time and financial source

Introdução: O referenciamento tardio (RT) para o acompanhamento nefrológico em pacientes com insuficiência renal crônica (IRC) está associado com um aumento da mortalidade. Em nosso meio, há dados escassos sobre o assunto, em especial com respeito à sua relação com a fonte de financiamento do acompanhamento especializado. Método: Análise retrospectiva de dados de pacientes em uma unidade satélite de hemodiálise. Considerou-se RT um período inferior a 120 dias entre o atendimento nefrológico e o início da hemodiálise (HD). Resultados: O RT aconteceu em 36,6% da amostra, foi associado com início de hemodiálise em caráter emergencial, com acesso por cateter venoso central e maior mortalidade (46,7% vs. 19,2%, p < 0,05,comparando ao grupo de eferenciamento precoce). A fonte de financiamento para 1/3 da amostra foi o Sistema Único de Saúde (SUS). Desse grupo, 66,7% foram referenciados tardiamente, apresentaram mortalidade de 21,4% nos primeiros três meses de tratamento, e 71% iniciaram a HD em regime de internação hospitalar. Discussão e Conclusões: Pacientes com insuficiência renal crônica referenciados tardiamente ao tratamento nefrológicoapresentam maior mortalidade, início do tratamento em caráter emergencial por acesso vascular temporário. Houve associação entre referenciamentotardio e o financiamento pelo SUS. Novos estudos são necessários para verificar a disponibilidade de atendimento especializado pelo SUS para a consolidação de uma política pública de atendimento ao renal crônico.

Introduction: Late referral (LR) of chronic renal failure patients to the nephrologist is related to increased mortality. There is little data in our country, particularly related to LR and the financial source of medical treatment. Methods: This was a retrospective analysis of patients’ reports in a non-hospitalhemodialysis unit. LR was defined when there was a period of less than 120 days between referral and initiation of hemodialysis. Results: LR occurred in36.6% of the patients and was related to the need of emergency hemodialysis (HD), use of central venous access, and increased mortality (46.7% vs. 19.2%,p < 0.05, in comparison to the early referral group). The funding for 33.3% of the patients was provided by the public health system (SUS). In this group of patients, 66.7% presented LR and increased mortality in the first 3 months of HD (21.4%). Moreover, 71% initiated HD in a hospital setting. Discussion and Conclusions: Chronic renal failure patients with LR presented increased mortality, need for emergency HD and temporary vascular access. There was an association between LR and public funding. Further studies are necessary to evaluate the availability of nephrology assistance by the public health system, in order to promote better care for the chronic renal failure patient.

Renal expression of COX-2, ANG II, and AT1 receptor in remnant kidney: strong renoprotection by therapy with losartan and a nonsteroidal anti-inflammatory.

Chronic renal injury can be mediated by angiotensin II (ANG II) and prostanoids through hemodynamic and inflammatory mechanisms and attenuated by individual suppression of these mediators. In rats with (5/6) renal ablation (Nx), we investigated 1) the intrarenal distribution of COX-2, ANG II, and the AT(1) receptor (AT(1)R); 2) the renoprotective and antiinflammatory effects of an association between the AT(1)R blocker, losartan (Los), and the gastric sparing anti-inflammatory nitroflurbiprofen (NOF). Adult male Munich-Wistar rats underwent Nx or sham operation (S), remaining untreated for 30 days, after which renal structure was examined in 12 Nx rats (Nx(pre)). The remaining rats were followed during an additional 90 days, distributed among 4 treatment groups: Nx(V) (vehicle), Nx(Los) (Los), Nx(NOF) (NOF), and Nx(Los/NOF) (Los/NOF). Nx(pre) rats exhibited marked albuminuria, hypertension, glomerulosclerosis, interstitial expansion, and macrophage infiltration, accompanied by abnormal glomerular, vascular, and interstitial COX-2 expression. ANG II appeared in interstitial cells, in contrast to S, in which ANG II was virtually confined to afferent arterioles. Intrarenal AT(1)R distribution shifted from mostly tubular in S to predominantly interstitial in Nx(pre). All these changes were aggravated at 120 days and attenuated by Los and NOF monotherapies. Los/NOF treatment arrested renal structural injury and ANG II expression and reversed hypertension, albuminuria, and renal inflammation. In conclusion, abnormal expression of COX-2, ANG II, and AT(1)R may be key to development of renal injury in Nx. Concomitant COX-2 inhibition and AT(1)R blockade arrested renal injury and may represent a useful strategy in the treatment of chronic nephropathies.

O efeito do bloqueio concomitante da ciclooxigenase e do receptor AT1 em ratos com nefropatia crônica estabelecida / A combined treatment of losartan and a nonsteroidal antiinflammatory affords superior protection of the remnant kidney

Para avaliar-se o papel da angiotensina II (AII) e dos produtos de degradação da ciclo-oxigenase (COx) nas nefropatias progressivas, ratos submetidos a ablação renal de 5/6 receberam losartan, um bloqueador de receptores AT1, e nitroflurbiprofen, um inibidor da COx. O tratamento combinado foi muito mais eficiente em interromper ou promover a regressão das alterações funcionais e histológicas que qualquer das monoterapias. Houve diminuição da infiltração renal de células inflamatórias e células expressando COx-2 e AII / Rats with 5/6 renal ablation received losartan, an AT1 receptor blocker, and nitroflurbiprofen, a cyclooxygenase (COx) inhibitor in order to evaluate the role of angiotensin II (AII) and COx end products in the progressive nephropathies. By acting on two distinct mechanisms, combined treatment exerted far more efficient protection than either monotherapy, arresting or promoting regression of functional and histologic manifestations of this model. There was a decrease in the number of infiltrating inflammatory cells and abnormal renal COx-2 and AII...

Evidence for the existence of two distinct functions for the inducible NO synthase in the rat kidney: effect of aminoguanidine in rats with 5/6 ablation.

The functional role of the NO synthase (NOS) isoforms in the normal or diseased kidney is uncertain. This study examined the renal expression of the endothelial (eNOS), neuronal (nNOS), and inducible (iNOS) isoforms by both immunohistochemistry and Western blot analyses in sham-operated rats (S) and in rats subjected to 5/6 nephrectomy (Nx). Primary antibodies from two different sources were used to detect iNOS. Additional S and Nx rats were chronically treated with aminoguanidine (AG), a selective iNOS inhibitor. All three isoforms were clearly expressed in S kidney. Their renal abundance, evaluated by Western blot analysis, fell in Nx rats. With the use of anti-iNOS antibodies from two distinct sources, the immunohistochemical analysis showed the presence of what appeared to be two distinct iNOS fractions: a "tubular" fraction, present in S and with decreased intensity in Nx; and an "interstitial" fraction, observed only in inflamed areas of Nx rats. AG treatment greatly attenuated renal injury in Nx rats by a direct antiinflammatory effect, likely related to iNOS inhibition, rather than to amelioration of renal hemodynamics or to reduced protein glycation. These observations suggest that: (1) the functional role of the renal iNOS isoform may vary dramatically under different physiologic conditions; (2) caution should be taken in the interpretation of immunohistochemical iNOS data, because antibodies from different sources may detect different iNOS fractions; and (3) AG treatment may become useful in the treatment of human progressive nephropathies, even those not associated with diabetes or aging.